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Predictive value of clinical risk
indicators in child development:
final results of a study based on
psychoanalytic theory*
Maria Cristina Machado Kupfer, Alfredo Nestor Jerusalinsky,
Leda Mariza Fischer Bernardino, Daniele Wanderley,
Paulina Schmidtbauer Barbosa Rocha, Silvia Eugenia Molina,
Léa Martins Sales, Regina Stellin,
M. Eugênia Pesaro, Rogerio Lerner
31
We present the final results of a study using the IRDI (Clinical
Risk Indicators in Child Development). Based on a psychoanalytic
approach, 31 risk signs for child development were constructed and
applied to 726 children between the ages of 0 and 18 months. One
sub-sample was evaluated at the age of three. The results showed a
predictive capacity of IRDIs to indicate developmental problems; 15
indicators for the IRDI were also highlighted that predict psychic risk
for the constitution of the subject.
Key words: Risk signals, child development, psychoanalysis,
developmental problems
*
The research was funded by the Department of Health, by the National Scientific and
Technological Development Council (CNPq), by the Research Support Foundation of
the State of São Paulo (FAPESP) and conducted at the Psychology Institute of the
University of São Paulo (IPUSP). Researchers in charge at FAPESP were: Maria
Cristina Machado Kupfer, Sandra Josefina Grisi, Mario Eduardo Costa Pereira and
Leandro de Lajonquière.
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Foreword
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Figures related to epidemiological incidence and prevalence
of development disorders and mental impairment in childhood
are inaccurate in most developing countries (Fleitlich and
Goodman, 2000). Various studies show considerable variations,
equally upsetting: from 10 to 20% of this specific population
seem to suffer from one of more mental impairments,
according to a report issued by the World Health Organization
(WHO, 2001).
The World Health Organization report (WHO, 2001) also
states that mental disorders are common during childhood and
adolescence, but the attention provided to this population
segment is rather insufficient, both regarding diagnosis and
treatment.
In England, a recent study found a 10% rate of psychiatric
disturbances prevalence in childhood, surveying 10,500 families
(Meltzer et al., 2000).
According to Williams et al (2004), around 15% of the
children cared for at pediatric services show behavioral
disorders, where the most common are attention deficit/
hyperactivity, and, often times, anxiety and depression.
There are already sufficient evidences that there is a
significant morbidity caused by the so called “emotional,
behavioral, development delay, psychosis, mental retardation and
epilepsy problems in this population” (Nikapota, 1991, p. 743).
Both the WHO report and the above mentioned studies
disclose that mental disorders in childhood are not irrelevant,
but they receive little attention from public policies, thus leaving
a high number of children without proper services.
The creation of instruments with indicators that are able
to detect, at an early stage of childhood, mental disturbances,
must be carried forward, considering the above reasons.
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The use of clinical risk indicators may find a significant application in the
field of mental health, especially as a useful tool in detecting development
problems in children.
The multiple centric research of children development clinical risk indicators
– hereinafter called CDRI research – presented here, strived to develop and validate
two instruments, in order to implement the first steps in this direction.
The CDRI research was conducted in the period from 2000 to 2008 by GNP
(see note 2) that developed, based on S. Freud and on the psychoanalytical
schools of W. Winnicott and J. Lacan, a tool composed of 31 clinical psychic risk
or development problems indicators in children, noticeable in the first 18 months
of the child’s life: CDRI.
Considering the many theoretical viewpoints regarding children’s
development and its psychopathology, we will list below the notions of
development and its problems adopted in this research.
Human development is conceived as the product of a double incidence: on
the one hand, are the maturity problems of neurological and genetic order, and,
on the other hand, the processes of constitution of the psychic subject.
Researches on development tend to privilege the neurological-genetic dimension
(Dargassies, 1974; Kandel et al., 1995; Rutther, 2006). In the CDRI research, we
privileged, without disconsidering the realm of maturity, the articulation between
the development and the psychic subject.
The subject is a notion that does not coincide with the notions of I or of the
personality, but an unconscious psychic instance. From the inception of the child’s
life, it is build, based on a preexisting social field, the history of a people, a family,
of the parents’ wishes – but also based on encounters, interchanges and hazards
that take place in the specific trajectory of the child. From the culture and
language field will come the keys of significance out of which the child should
build for itself a unique place. Out of this process, the psychic subject will arise,
as an organizing element of the child’s development in all of its dimensions –
physical, psychomotor, cognitive and psychic Jerusalinsky, 1989; Bernardino,
2007; Kupfer, 2009).
Maturity, growth, and mainly the development depend on the processes of
psychic life formation and are extremely sensitive to them. These formation processes operate under the rule of others that surround the child and are responsible
for its care and evolution.
Although unique, the place (locus) of a subject depends on general actions
that every caregiver is expected to perform in the early childhood, without which
this place runs the risk of not being created.
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Regarding the “development problems”, the CDRI research considered that
they may be divided into two types: In the first type, development problems point
out to the presence of subjective difficulties that affect or are incident on the
child’s development, but do not challenge the installation of the psychic subject.
Examples of these clinical situations may be: hyperactivity, issues with laws and
rules, enuresis. The second type, also called “problems in subjective constitution”,
covers development difficulties that point out to hurdles in the subjective
constitution process itself. They indicate more structural problems, pointing out
to evolution risks more geared to serious psychopathologies in childhood, such
as global development disorders, whose psychiatric definition is found in DSMIV-TR (American Psychiatric Association – APA, 2002).
The main goals of the CDRI research were to check the power of indicators
for an early detection of development problems in early childhood, and to select
psychic development indicators to be included in the follow-up file of the
Development of Children aged from zero to five, proposed by the Department of
Health.
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Methodology
Research design, studied area, sampling and procedures
The study used first, a transverse section and then a longitudinal section. The
sample consisted of 727 children in the age brackets from 0 to 4 months, still to
be complete, 4 to 8 incomplete months, 8 to 12 incomplete months, and 12 to
18 months, selected randomly among those who sought routine pediatric
consultations at 11 health care services in nine Brazilian cities (Belém do Pará,
Brasília, Curitiba, Fortaleza, Porto Alegre, Recife, Rio de Janeiro, Salvador and
São Paulo with three healthcare centers). The pediatricians that applied the CDRI
protocol were trained for the purpose.
The present, absent and not-checked clinical indicators ( CDRI ) were
registered during the study. In this survey it is the absence of indicators that
suggests a risk for the child’s development. Thus, the CDRIs, when present, are
indicators of development, and when absent, they point out to risk for the
development.
At the end of 18 months, 287 children showed 2 or more absent indicators
(considered cases), and 440 showed 1 or 0 absent indicator (control child).
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Among the cases, 183 children were chosen by lot (64%); out of them, 158
completed the study (13,7% loss). Among control children, 132 (30%) were
chosen by lot; out of them, 122 (7,5% loss) completed the study.
When the children of this sub-sample reached the age of 3, they were
submitted to a psychiatric and psychoanalytical diagnosis, using two protocols
created for the purpose: the Psychoanalytical Evaluation script AP3 – and the
Psychiatric Evaluation script. This article will approach only the results achieved
by means of the psychoanalytical evaluation, while the psychiatric assessment
results will be used in a future article.
Based on the psychoanalytical evaluation, a table of clinical symptoms was
set up. Then we defined the clinical outcome for the research: a) presence or
absence of development problems for the child, or b) presence or absence of risk
for the constitution of the subject.
Considering that they are new tools, we will list below the theoretical
Fundamentals that justify the choice of the indicators, the axes and clinical
outcomes used in the CDRI research.
The construction of the CDRI Instrument
(Child Development Risk Indicators)
The CDRI 31 indicators were developed based on the following theoretical
axes and are considered their expression of the phenomena. Assumption of
subject, establishment of demand, alternate presence/absence and paternal
function. The outline of these axes was based on the works Three Contributions
to the Theory of Sexuality (Freud, 1905), Beyond the Pleasure Principle (Freud,
1920) and The dissolution of the Oedipus complex (Freud, 1924) and on the 4
and 5 seminars by J. Lacan (Lacan, 1995, 1999).
This study assumes that the maternal work is gradually woven around these
four axes, and its outcome is the installation of a psychic subject, based on which
a child’s development is organized.
The axis “subject assumption” ( SA ) characterizes an anticipation, by the
mother or caregiver, of the presence of a psychic subject in the child, that,
however, has not yet been constituted. This constitution depends exactly on the
fact that this subject is initially assumed or anticipated by the mother (or
caregiver). This anticipation gives the child a great pleasure, since it is
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accompanied by an expression of joy from the mother – words loaded with a
pleasurable musicality, called motherese (Ferreira, 1997; Laznik, 2000), and this
will make the child “strive” to correspond to what was anticipated about it. In
this attempt, the child will bring back the pleasure experienced at the time of the
mother’s anticipation – the frown, translated by the mother as a smile, will really
become a smile. Thus, the subjectivity that had not yet been installed may be
effectively built.
In the “demand establishment” axis, (DE), the first involuntary responses
that the child presents at birth are collected, such as crying, which will be
recognized by the mother as a request made by the child to her. This recognition
will allow for the construction of a demand, – for psychoanalysis, always a
demand for love – from this subject to all those he/she will relate to. This demand
will be at the basis of all future activities of language and relationships with others.
The “alternate presence/absence” (PA) axis characterizes the mother actions
that make her alternately present and absent. The mother’s absence will mark all
human absence as an existential occurrence, noteworthy, compelling the child to
develop a subjective mechanism to symbolize it. The mother’s presence will be
not only physical, but mainly symbolic. Between the child’s demand and the
experience of satisfaction provided by the mother, we expect an interval, where
the child’s response may appear, a basis for future responses or demands. Finally,
in the “paternal function” ( PF ) axis, we seek to follow-up the effects of this
function on the child, that determines the weight of the mother’s actions. We
understand that the paternal function occupies, for the mother-child couple, the
place of a third instance, oriented by the social dimension. A mother that is
submitted to the paternal function takes into account, in her relationship with the
child, the parameters proposed by culture to guide this relation, since the paternal function is in charge of transmitting these parameters. The exercise of the
paternal function on the mother-child couple may have the effect of a symbolic
separation between them, and will prevent the mother from considering her child
as an “object” focused solely on her satisfaction. Therefore, the singularity of the
child and his/her differentiation regarding the mother’s body and words depend
on this function.
Table 1 shows the indicators with the annotations SA, DA, PA and PF, that
indicate the axes to which they refer.
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Table 1
Child Development Clinical Risk Indicators and respective theoretical axes
Age in months:
Indicators:
0 to 4 months
incomplete:
1. When the child cries or screams, the mother knows what
the child wanes.
2. The mother talks to the child in a style that is particularly
addressed to the child (motherese).
3. The child responds to motherese.
4. The mother proposes something to the child and waits
for the response.
5. Mother and child exchange eye-contact.
SA
DA
6. The child starts to differentiate day from night.
DA/AP
7. The child uses different signs to express different needs.
8. The child demands the mother and gives some time to
wait for her response.
9. The mother talks to the child addressing short sentences
to him/her.
10. The child responds (sound, vocals) when the mother or
somebody else addresses him/her.
11. The child actively seeks contact with the mother’s eyes.
12. The mother supports the child´s initiatives without
stopping his/her efforts.
13. The child asks for help from somebody else without
remaining passive.
DA
4 to 8 months
incomplete:
'
8 to 12 months 14. The mother understands that some demands from the child
incomplete:
may be a way to call her attention.
15. During body care, the child searches actively to play
loving games with the mother.
16. The child shows that it likes or dislikes something.
17. Mother and child share a private language.
18. The child feels ill at ease with unknown people.
19. The child has favorite objects.
20. The child shows cute behavior.
21. The child looks for the adult’s approval look.
22. The child accepts semi-solid and varied foods.
From 12 to 18 23. The mother alternates moments of dedication to the
months
child with other interests.
24. The child endures well the mother’s brief absences and
reacts to longer absences.
25. The mother offers toys as alternatives to the child’s
interests in the mother’s body.
26. The mother no longer feels compelled to meet all demands
from the child.
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Axes
SA/DA
AP
SA/AP
DA/AP
SA/AP
DA
DA/AP
SA/DA/AP
DA/PF
DA/SA
DA
DA
SA/AP
PF
DA
DA
DA
DA
DA/PF
DA/PF
DA/PF
PF
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27. The child looks curiously to things that interest the mother.
28. The child likes to play with objects used by the mother and
by the father.
29. The mother starts to ask the child to speak out what he/she
wants, not being satisfied with gestures only.
30. Parents establish small behavior rules for the child.
31. The child differentiates between objects belonging to the
mother, father and him/herself.
SA/PF
PF
PF
PF
PF
Validation instrument: Psychoanalytical evaluation at the age of 3. (PE3)
38
Psychoanalytical Evaluation at the age of 3 – PA3 – was also developed by
the same group of researchers responsible for developing CDRI. It consists of a
script, to be used by psychoanalysts, containing forty-three questions that will
guide the interview. This interview is conducted with parents and the child during
approximately one hour and thirty minutes. After the interview, the psychoanalyst
will write a qualitative report and also indicate the possible presence of clinical
symptoms.
AP3 was developed based on the four axes used to build CDRI (SA, DA, AP
and PF), but it was also based on four new categories, to cover what one expects
to find in the psychic functioning of a three-year old child. The research was
focused on establishing the relationship between the already applied indicators, in
what they evidenced about the first operations that formed subjectivity, and the
effects that these operations brought about. The chosen categories include exactly
these effects, via their expression in clinical symptoms.
The new landmarks of this construct are expressed in the following
categories: Playing and fantasy (PF); The body and its image (BI); Expression
before rules and position regarding the law (PL); Speech and position in Language
(SL).
Below, a summary of what A. Jerusalinsky (2008) proposed to guide the
evaluations, based mainly on J. Lacan (1966; 1969; 2003), F. Dolto (1992) and
D. Winnicott (1975).
1. Playing and Fantasy: Playing is a way to express, in a free associative
manner, the unconscious fantasy of the child. In the case of a complete absence
of an imaginary production, the child’s game appears glued to the mechanics of
objects and it does not unfold, in its constructs, a narrative. Playing can also
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appear without any reference to make-believe, to the limits and interdictions.
Significations may be random, fragmented, but the child shows an intense
relationship with the other, opposite to what happens in cases of lack of imaginary
productions. Finally, the drawings and games of a child may be understood as
significations at the service of a story, of a narrative or of a piece of information,
and then, the limits, the prohibitions and the figurative feature of the characters
arise. In this case, playing may be a form of symbolizing his/her difficulties,
conflicts, failures and concerns.
2. The body and its image: the body image is a construct that arises as a
result of the mother’s actions on the child’s body, changing it into a signification
system. This system allows that child to learn about him/herself in a psychic
image, unified, base on which the child will be able o recognize him/herself. The
body image also contains the traces of sexual differentiation. Discrepancies in
activity, movement, aesthetic-sexual differentiation, self-recognition expressions
and the presence of inhibitions show the presence of clinical symptoms.
3. Expression vis-a-vis rules and position regarding the law (PL): Compliance
with limits, restriction of one’s own impulses in accordance with the situation,
permeability of the subject as to schedule of times and activities, respond, in general, to the interiorization of paternal interdiction, that different forms of the lay
may adopt. Therefore, also speaking generally, we can mention that the lack or
intermittence of such behaviors usually point out to the presence of clinical
symptoms.
4. Speech and position with regard to language: A child’s speech indicates
that he/she entered a field that goes beyond speaking: the field of language. This
field covers other expressions, but is not restricted to them. The child’s entrance
in the field of language is not measured only by his/her vocabulary, by the
mastering of syntax and grammar, or by mastering other language expressions,
such as gestures, for instance. This entrance is measured mainly by the place
from which the subject represents him/herself in the language’s system, disclosing
his/her possibility of positioning him/herself regarding the significations of the
world, his/her possibility of supporting relationships with others, of recognizing
in the language the demand and desire of others, and of producing, on his/her
turn, new significations.
The proposed psychoanalytical evaluation was neither an exhaustive nor a
limitative investigation. It viewed only at ensuring a certain homogeneity of the
interviews, as well as to collect sufficient material to establish an assumption
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about the process of psychic constitution in the evaluated children. What we
intended, ultimately, was to register if this psychic constitution is in progress or
at risk.
The instrument’s development followed the post-hoc construction
methodology, permitting a gradual adaptation of the findings to the evaluation
tables. Thus, at the completion of 208 evaluations, we achieved a table where the
55 clinical symptoms detected in the evaluations are present.1
Two types of clinical outcome of the research were defined, based on the
results of the psychoanalytical evaluation: a) presence of absence of development
problems proper for the child, or b) presence of absence of development problems
with psychic risk for the constitution of the subject.
The two clinical outcomes received abridged names: a) presence or absence
of development problems, and b) presence or absence of psychic risk.
The first type of clinical outcome – presence of development problems for
the child – points out, generally, to the existence of psychic difficulties and vicissitudes that are interfering in the child’s development, without meaning,
however, that the psychic structure is impaired. A child with enuresis, for instance,
shows, by means of the disorganization of the excreting function that something
is not well in his/her relation with the world or with him/herself, although there
is nothing wrong with his/her physiology.
For the establishment of the second type of clinical outcome – presence or
absence of risk for the subject constitution – a previous study was conducted by
Jerusalinsky and Infante,2 based on current literature on children psychopathology
( DSM-IV-TR , Marcelli & Cohen, 2009). Starting from this study, among the
clinical symptoms that were found, they located the symptoms that could point
out to the presence of a psychic risk for the constitution of the subject. These
symptoms were called psychic risk indicators or symptoms.
Clinical symptoms or psychic risk indicators indicate arrests or absence of
what should be in progress. The absence of make-believe, for instance, shows
an interruption or lack of the fantasy device as an instrument for the elaboration
of the difficulties that every child has to face during growing, and indicates a
1. For the clinical symptoms, see Lerner, R. e Kupfer, M.C.M. (Orgs.). Psicanálise com crianças: clínica e pesquisa.
2. Non-published study.
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significant arrest in the subject constitution. In order to be included in the group
of children that presented psychic risk for the subjective constitution – hereinafter
called only psychic risk – the child should present at least one of these symptoms
or psychic risk indicators.
Statistical analysis
Based on the results achieved in PA3, we proceeded with the analysis for the
validation of CDRI for the forecast of psychic risk and development problems,
establishing the respective relative risks with the computation of intervals of
confidence at 95%. This validation analysis was conducted in two ways:
considering the instrument as a whole and taking each of the 31 indicators
individually.
Sets of indicators (Factors) were extracted in each period by means of an
Analysis of Main Components (AMC), and later on, studied according to their
capacity to foresee psychic risks and development problems. In order to be
considered case, the child needed to have at least one absent indicator, among
those that made up the factor.
The analysis of main components (AMC) studied the interdependence of the
investigated variables.
Correlation matrixes containing the answers to the questions of each
assessment period were used for the AMC. For the determination of the number
of factors in the AMC, the criteria used was to maintain the factors corresponding
to the matrix “eigenvalues” higher than the unit. After the factoral loads matrix
was found, the Varimax rotation method was used. The factoral loads matrix run
was used for the interpretation of factors and only those with values over 0.40
were considered.
Results
Statistical analysis pointed out that CDRI as a whole has a greater capacity
to predict development problems than to predict psychic risk.
Additionally, it pointed out some indicators, either individually or in groups,
with the capacity of predicting psychic risk or development problems, as shown
in table 3.
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Table 3
Predictive analysis of cases identified in CDRI (absence of two or more
indicators until the age of 18 months) presented psychic risk or
development issues at the age of 3.
Ratio of positives
IDRI
cut 1/2
Total
current indicators
Psychoanalytical
clinical evaluation
Cases
Controls
Psychic Risk
19.6%
11.5%
16.1%
Development problems*
70.3%
57.4%
64.6%
Total
158
122
280
Note: *statistically significant result.
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Table 4 shows the four indicators that were capable of predicting statistically
significant psychic risk, and two indicators that were capable of predicting
development problems.
Table 4
Individual indicators that were capable of predicting psychic risk
and development problems
Indicator
Relative Risk
Interval of confidence 95%
3.46
1.19 – 10.07
Psychic risk
7. The child uses different signs to express
different needs
18. The child feels uncomfortable with unknown
people.
2.93
1.49 – 5.73
22. The child accepts semi-solid, solid and
varied foods.
3.75
1.37 – 10.28
30. Parents establish small behavior rules for
the child.
4.19
1.74 – 10.06
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Development problems
24. The child is able to accept well brief
absences of the mother and reacts against
longer periods of absence.
2.83
1.26 – 6.35
26. The mother no longer feels she is obliged to
do everything the child requests.
3.01
1.11 – 8.14
The following sets indicators, after factorial statistic analysis, had a
significant correlation in predicting psychic risk:
• in the 0 to 4 months range: all five indicators make up one single factor that is
significant to predict psychic risk (RR=3.51; CI95% 1.10-11.17).
• in the 4 to 8 months range there is a factor made up of indicators 6,7,8,9 which
is significant to predict psychic risk (RR=2.50; CI95% 1.01-6.59).
• in the 8 to 12 months range there is a factor made up by indicators 16 and 22
which is significant to predict psychic risk (RR=5.01; CI95% 1.97-13.15).
• in the 12 to 18 months range there is a factor made up by indicators 23, 24,
26 and 30 which is significant to predict psychic risk (RR=1.99; CI95% 1.033.85) as well as to predict development problems (RR=2.82; CI95% 1.45-5.45).
A new CDRI was developed based on these results, where we find the 15
indicators able to predict psychic risk: 1, 2, 3, 4, 5; 6, 7, 8, 9; 16, 22; 23, 24,
26 and 30.
Discussion
The Multicentric Research of Risk Indicators for Children Development
validated CDRI as an instrument with the capability to forecast development
problems in 3-year old children.
The instrument as a whole may indicate that a child shows development
problems, but it does not indicate a trend, at the age of three, towards serious
disorders.
From the viewpoint of the development notion used in this research, the
value of the CDRI instrument lies in providing the timely location of problems, that,
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once detected, and properly treated, will give the child a richer and more creative
development process, with much less suffering.
The research has also found some indicators, signalized either individually
or in factoral matrixes that showed a high capability of forecasting psychic risk
in general and with no specification of pathology. The pathology specification was
not, really, the intent of this study, at least at the first stage. It is well known that
to find more serious pathologies, such as children’s autism, with a small incidence
in the general children’s population, (considering the typical circumstances), it
would require a much larger sample, but this sample was not developed, since
this was not the purpose. Therefore, new researches should be proposed, where
cases will be followed-up until the age of 5, in order to confirm the risk trend
appointed by this survey. A broader sample should also be collected, for the
location of cases of autism.
Four individual indicators, and three groups of indicators showed this
sensitivity of indicating a trend towards the risk of hurdles in the process of
subject constitution, and, therefore, indications of psychic risk. Thus, this set
of 15 indicators may also permit the early location of risks of serious pathologies,
thus putting the research at the service of a very current trend in international
research, the search for instruments for the detection and prompt intervention at
a time of development when a reversion of the situation may still be possible.
Mazet and Houzel (1996) draw attention to the difficulty or reverting disorders
once they are installed, in the case of children’s psychosis, cases of deficiency
or psychopathologies. In their opinion, it is of essence to avoid to the maximum
the installation of these traits. “Experience has shown that frequently, the
reversibility of disorders was a result of how early they are identified and treated”
(p. 547).
The choice of the beginning of the fourth year of life as the time for
assessing the children in the research was also due to the logics of prevention that
permeates the entire work of the group. This has to do with proposing detection
strategies that will allow for a timely intervention, that is, at a time when the
highest levels of the psychic apparatus are still under construction, before the
psychopathological processes get installed. As Laznik (2004) states, “the clinical
practice teaches us how the institutions of the psychic apparatus are done early,
and this leads us to regret not having found the children at an earlier stage, when
the game was not yet decided” (p. 22). For this author, it is important to consider
the “sensitive period” for the various acquisitions of childhood. She states: “even
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if the plasticity of the psychic apparatus permits the additions that may be done,
the age when we intervene is a crucial piece of information” (2004, p. 31).
The same logics also permeate the concept of 0-3 Diagnostic Classification
(1997), that highlights the “importance of prevention and early treatment in the
creation and restoration of favorable conditions for mental development and health
of small children” (p. 9), to the extent where, according to the scale’s authors,
the early detection permits intervening before the first deviations are consolidated
into functioning patterns that are little adaptive.
The validation of indicators also confirms the value of their bases – the axes
– a consistent theoretical foundation that guides the interpretation of the
subjectivity constitution. These axes are already being used in papers on children
development (J. Jerusalinsky, 2002; Teperman, 2005; Bernardino, 2006), since
they have come to fill a gap existing in most books on this subject, that usually
approach in detail the evolutionary aspects – related to body functions and instrumental skills of children – without having a consistent theoretical basis for the
structural aspects of early childhood. These aspects are the organizers of both
body and instrumental functions. The axes “subject assumption”, “establishment
of demand”, “alternance between presence and absence”, and “paternal function”
allow us to drill down – in the plan of interactions between children and parents
– the two essential functions for the advent of subjectivity: the maternal function
and the paternal function (Lacan, 1995; 1999).
At the same time, the results show that the indicators with the stronger
predictive power are those related to the last surveyed development bracket (12
to 18 months), whose prevailing theoretical axis is the paternal function. This
finding evidences the psychoanalytical assumption that the paternal instance is
introduced at the early times of subjectivity in a veiled way, and its effects start
to be noticed as of the second year of life (Lacan, 1966).
In the direction, that is underscoring a function as necessary and present
since the primordial time of childhood, one may consider that the presence of the
15-indicators set has the value of resilience. This, CDRI may be used as a set of
indicators valid for the configuration of the child’s psychic health.
In the CDRI research, it is the absence of indicators that indicates
disturbances in the unfolding of the mother-child dialogue, and therefore, a risk
for the child’s development. Therefore, when the CDRIs, are present, they are
indicators of development, and when absent, they indicate risk for the
development.
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This distorsion was introduced on purpose. Once included in a regular
examination protocol, the indicators, conceived in a positive manner, may operate
in the direction of creating a pediatric view that sees psychic health and not
psychic disease in the child. When absent, they will lead the pediatrician to
suspect that something is not going well, without leading him/her to make a final diagnosis. In the field of subjectivity, a diagnosis closed in the early childhood
may the disastrous and iatrogenic, to the extent it closes a fate still subject to
changes arising from the plasticity and the intercurrences that contribute, as
already mentioned, to the singular construction of a subject locus (Winnicott,
1966).
At the first stage of the research, the dialogue was with the pediatrics field,
in the general environment of health and prevention. However, at the second
stage, dialogue was with the field of psychopathology, in the realm of childhood
disorders. In this direction, there was a change in paradigms, since the target
became the detection of development problems. Thus, the clinical symptoms
searched by the Psychoanalytical Evaluation are indicators whose presence points
out to development problems or even psychic risk. The logic that governed the
construction of indicators was once again reversed, since we are now in the realm
of psychopathology and treatment, and no longer in the realm of pediatrics.
The attempt to articulate the statistical and clinical methods is rarely found
in scientific literature. However, this scenario is changing: authors such as Hanns
(2000), Pereira (2001), Mezan (2002), consider that it is possible to make
psychoanalysis dialogue with Modern Science, having the care of not eliminating
the differences.
One of the main goals of this research was to include psychic indicators in
the Department of Health Growth and Development Follow-up File, and they are
now available for this purpose. Thus, psychoanalysis, more than dialoguing with
the Modern Science, has opened a door for its participation in the Public Health
actions in Brazil.
Acknowledgements
To Dr. Josenilda Caldeira Brant (in memoriam), who idealized this research.
To Prof. Dr. Sergio Baxter Andreoli, from the Psychology and Medical
Psychiatry of the Federal University of São Paulo, statistical analyst of the
research.
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Abstracts
(Valor preditivo de indicadores clínicos de risco para o desenvolvimento infantil: um
estudo a partir da teoria psicanalítica)
No presente artigo, apresentam-se os resultados finais da Pesquisa IRDI. A partir
da psicanálise, 31 indicadores clínicos de risco para o desenvolvimento infantil (IRDI)
foram construídos e aplicados em 726 crianças entre 0 e 18 meses. Uma sub-amostra
foi avaliada com a idade de 3 anos. Os resultados apontaram a capacidade dos IRDI
para predizer problemas de desenvolvimento e destacaram ainda 15 indicadores do
IRDI com capacidade para predizer risco psíquico para a constituição subjetiva.
Palavras-chave: Indicadores de risco, desenvolvimento infantil, psicanálise,
problemas de desenvolvimento
(Valor predictivo de indicadores clínicos de riesgo para el desarrollo infantil: un
estudio a partir de la teoría psicoanalítica)
El presente artículo presenta los resultados finales de la pesquisa IRDI. Desde el
psicoanálisis, 31 signos de riesgo para el desarrollo infantil (IRDI) se han construido
y aplicado a 726 niños entre 0 y 18 meses. Se evaluó una sub muestra a los 3 años de
edad. Los resultados muestran que los IRDI poseen una capacidad de predecir
problemas de desarrollo. 15 signos muestran una capacidad de predicción de riesgo
psíquico para la constitución subjectiva.
Palabras clave: Signos de riesgo, desarrollo infantil, psicoanálisis, problemas de desarollo
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(Valeur prédictive d'indicateurs cliniques de risque pour le développement de
l'enfant: une étude à partir de la théorie psychanalytique)
Cet article présente les résultats de la recherche IRDI. A partir de la psychanalyse,
31 signes cliniques de risque pour le développement de l´enfant (IRDI) ont été
développés et appliqués à 726 enfants à l’âge entre 0 et 18 mois. Un sous-échantillon
a été évalué à l´âge de trois ans. Les résultats ont montré que les IRDI ont la capacité
de prédire des problèmes de développement. Un groupe de 15 signes prévoit d'ailleurs
le risque psychique de la constitution subjective.
Mots clés: Signes cliniques de risque, développement de l'enfant, psychanalyse,
problèmes de développement
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Citação/Citation: KUPFER, M.C.M.; JERUSALINSKY, A.; BERNARDINO, L.F.; WANDERLEY, D.;
R OCHA , P.; M OLINA , S.; S ALES , L.; S TELLIN , R.; P ESARO , M.E.; L ERNER , R. Clinical risk
indicators for child development: final results of a psychoanalytical theory-based study.
Revista Latinoamericana de Psicopatologia Fundamental, São Paulo, v. 13, n. 1, p. 31-52,
mar. 2010.
Editor do artigo/Editor: Prof. Dr. Manoel Tosta Berlinck
Recebido/Received: 11.5.2009/5.11.2009
Aceito/Accepted: 15.6.2009/6.15.2009
Copyright: © 2010 Associação Universitária de Pesquisa em Psicopatologia Fundamental/University Association for Research in Fundamental Psychopathology. Este é um artigo de livre acesso, que permite uso irrestrito, distribuição e reprodução em qualquer meio,
desde que o autor e a fonte sejam citados/ this is an open-acess article, which permits
unrestricted use, distribution, and reproduction in any madium, provided the original author
and source are credited.
Financiamento: Esta pesquisa foi financiada pelo Ministério da Saúde do Brasil e pela
Fundação de Apoio à Pesquisa do Estado de São Paulo – Fapesp/This research has been
funded by the Ministry of Health, Brazil, and by Fondation for Research Support of the
State of Sao Paulo.
Conflito de interesses: Os autores declaram que não há conflito de interesses/The authors
declares that they have no conflict of interest.
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MARIA CRISTINA MACHADO KUPFER
Professora titular do Instituto de Psicologia da Universidade de São Paulo – USP (São Paulo, SP, Brasil); psicanalista; presidente do Conselho de Administração da Associação Lugar de Vida.
R. Heitor de Andrade, 40
05441-020 São Paulo, SP, Brasil
e-mail [email protected]
ALFREDO NESTOR JERUSALINSKY
Doutor pelo Instituto de Psicologia da Universidade de São Paulo – USP (São Paulo, SP,
Brasil); psicanalista; mmbro da Associação Psicanalítica de Porto Alegre.
Rua Genaro Petersen Junior, 636
90540-140 Porto Alegre, RS, Brasil
e-mail: [email protected]
LEDA MARIZA FISCHER BERNARDINO
Professora titular da Pontifícia Universidade Católica do Paraná – PUC-PR (Curitiba, PR,
Brasil); psicanalista; analista membro da Associação Psicanalítica de Curitiba.
Av. do Batel, 1920/210
80420-090 Curitiba, PR, Brasil
e-mail: [email protected]
DANIELE WANDERLEY
Especialista em Psiquiatria da criança (Paris V) e Psicopatologia do bebê (Paris XIII).
R. Desembargador Baldoino de Andrade, 211/401– Chame-Chame
40157-180 Salvador, BA, Brasil
e-mail: [email protected]
PAULINA SCHMIDTBAUER BARBOSA ROCHA
Linguista; psicanalista; membro do Círculo Psicanalítico de Pernambuco e do Centro de Pesquisas em Psicanálise e Linguagem (CPPL) (Recife, PE, Brasil).
Rua João Ramos, 231/401
52011-080 Recife, PE, Brasil
e-mail: [email protected]
SILVIA EUGENIA MOLINA
Psicanalista, Centro Lydia Coriat (Porto Alegre, RS, Brasil).
Av. Independência 944
90035-072 Porto Alegre, RS, Brasil
e-mail: [email protected]
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LÉA MARTINS SALES
Professor Adjunto da Faculdade de Psicologia da Universidade Federal do Pará – UFPA (Belém,
PA, Brasil); psicanalista; analista membro da Associação Psicanalítica de Porto Alegre.
Travessa 9 de janeiro, 2196, casa A
66063-260 Belém, PA, Brasil
e-mail: [email protected]
REGINA STELLIN
Mestre em Psicologia Clínica pela Pontifícia Universidade Católica de São Paulo – PUCSP (São Paulo, SP, Brasil).
Avenida Professor Joaquim Silva, 325/104
18085-000 Sorocaba, SP, Brasil
e-mail: [email protected]
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M. EUGÊNIA PESARO
Doutoranda do Instituto de Psicologia da Universidade de São Paulo – USP (São Paulo,
SP, Brasil); psicanalista; membro da Associação Lugar de Vida.
Rua Domingos Fernandes, 700/131
04509-011 São Paulo, SP, Brasil
e-mail: [email protected]
ROGERIO LERNER
Professor Doutor do Instituto de Psicologia da Universidade de São Paulo – USP (São
Paulo, SP, Brasil); psicanalista; membro da Associação Lugar de Vida.
Rua Prof. Mello Moraes, 1721
05508-030 São Paulo, SP, Brasil
e-mail: [email protected]
The research was carried out by the GNP Group, a group of experts invited by Maria Cristina Machado Kupfer, from IPUSP, to build the indicators protocol and to conduct the multiple
center research at the various centers. The group consisted of Leda M. Fischer Bernardino,
from PUC-Curitiba; Paula Rocha and Elizabeth Cavalcante, from CPPL – Recife; Domingos
Paulo Infante, Lina G. Martins de Oliveira and M. Cecília Casagrande, from São Paulo; Daniele
Wanderley, from Salvador; Lea M. Sales, from the Federal University of Pará; Profa. Regina
M. R. Stellin, from UNIFOR – Fortaleza; Flávia Dutra, from Brasília; Octavio Souza, from
Rio de Janeiro; Silvia Molina, from Porto Alegre; under the technical coordination of M.
Eugênia Pesaro, scientific coordination, of Alfredo Jerusalinsky and national scientific
coordination of Maria Cristina M. Kupfer.
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